Abstract： Objective To explore the diagnosis and treatment of descending necrotizing mediastinitis (DNM). Methods We retrospectively analyzed the records of eight DNM patients treated at Tangdu Hospital between 2006 and 2009 year. There were 7 males and 1 female aged from 21-98 years with a median age of 49.5 years. The diagnostic criteria included clinical manifestations, neck and chest CT scans, and bacteriological culture. Six of the patients had odontogenic infections and six had diabetes. Antibiotic treatment, incision drainage, and other symptomatic treatments were applied. Two patients received cervical incision drainage, five received thoracotomy, and one received video-assisted thoracoscopic surgery (VATS). Results After treatment, six patients recovered and two died of heart failure and neck vessel rupture. According to the bacterial culture, six patients presented mixed infections, and four of these presented mixed aerobic and anaerobic infections. The mean operation time was 75.6 minutes, the average volume of pus removed during the operation was 318.7 ml, and the average inpatient stay was 18 days. At six months follow-up, all six surviving patients showed improvements in quality of life. Conclusion The valid diagnosed criteria of DNM include history, sign, symptom, neck and chest CT scanning, and secretion culture.DNM mortality can be reduced by employing broad spectrum antibiotics early in treatment, individual surgical managements, and effective treatments for complicating illnesses.
Descending necrotizing mediastinitis （DNM）is a severe infection spreading from the cervical or odontoiatric region to the mediastinum through the anatomic cervical spaces. DNM is very rare but fatal. The course of the illness proceeds rapidly and the mortality rate is high. The pathogenic process is closely related to anatomical and physiological characteristic of cervix and mediastinum. The most valuable way for decreasing its high mortality rate is to give early diagnosis and treatments. Computed tomography(CT) scan is especially important method in early diagnosis.The early and enough use of broad spectrum antibiotics, individual surgical management based on neck and chest CT, such as clearing necrotic tissues,drainage and flushing are all effective methods to decrease mortality rate. Related management , such as department of stomatology, head and neck surgery, thoracic surgery,intensive care unit, and infectious department,should give cooperative therapy when necessary. At the same time, more attention should be paid to the patients who have some systemic disease such as diabetes mellitus and whose physical constitutions are very poor, which could lead to DNM and worsening. It can help to decrease the incidence rate of fatal complications and to increase cure rate.
ObjectiveTo explore the etiology, clinical manifestation, computed tomography (CT) manifestations, pathological character, diagnosis, differential diagnosis, and treatment of fibrous mediastinitis in China.MethodsThe clinical data of a patient with fibrous mediastinitis admitted to Hospital of Sichuan Provincial Armed Police Force were retrospectively analyzed and the related literature was reviewed. A literature research was performed with " fibrous mediastinitis, mediastinal fibrosis, sclerosing mediastinitis, chronic mediastinitis ”as the Chinese key word in WanFang database and China national knowledge internet, and " fibrous mediastinitis, mediastinal fibrosis, fibrosis of mediastinum, fibrosing mediastinitis, sclerosing mediastinitis, chronic mediastinitis” as English key words in PubMed database. The time interval was from January 1980 to December 2016.ResultsThe patient was a 59 year old male, whose chest CT scan showed soft tissue density in pulmonary hilar and mediastina, with bronchus truncation and obvious stenosis of pulmonary artery in hilar. Literature review found 12 related articles reporting 37 cases of fibrous mediastinitis in China. Fifteen cases were caused by tuberculosis infection presumably, and 9 cases were idiopathic mediastinal fibrosis. The common clinical manifestations were cough, dyspnea, chest tightness and pain, fever, and edema. CT manifested soft tissue density in pulmonary hilar and mediastina, which were diffuse in 32 cases. Trachea and bronchus were involved in 26 cases, while pulmonary artery in 29 cases, pulmonary vein in 13 cases, plural effusion in 16 cases, and vena cava and its branch in 8 cases. Other involved regions were described in 18 cases, including aorta and its branch in 4 cases, esophagus in 1 case, and there were pericardial effusion in 6 cases. Fourteen cases had pathology results.ConclusionsThe most common etiological factor of fibrous mediastinitis in China is tuberculosis infection, secondly idiopathic mediastinal fibrosis. Clinical manifestation is nonspecific. mostly diffuse, surrounding bronchus, esophagus and blood vessels in hilar and mediastina, and sometimes infiltrating into pericardium and pleurae. Its pathological character is proliferation of fibrous tissue, with proliferation of lymphocytes, and without envelope. The diagnosis depends on CT and pathology. Corticosteroid is considered to treat idiopathic mediastinal fibrosis, while surgery and vascular interventional therapy may improve symptoms of vascular compression in mediastina.
ObjectiveTo investigate the clinical features and prognosis of fibrinous mediastinum and evaluate the value of different examinations in diagnosis and evaluation. MethodsTwenty-eight patients with mediastinal fibrosis diagnosed between January 2015 and September 2020 in China-Japan Friendship Hospital were studied retrospectively. The Clinical manifestations, radiological characteristics, endoscopic features, echocardiography, V/Q SPECT, cardiac catheterization, treatment and prognosis were analyzed.ResultsThe main clinical symptoms were cough (77.6%), expectoration (57.1%), wheezing or suffocating (42.9%), dyspnea (39.3%). There were 67.9% of the cases who were considered previous or present tuberculosis. Imaging findings showed that the fat density in the mediastinum disappeared, the irregular soft tissue of the mediastinum surrounded the airway and pulmonary vessels, and many lymph nodes enlarged and calcified, and multiple bronchus and pulmonary vessels were compressed and narrowed. Pulmonary function was mainly manifested as obstructive ventilate dysfunction and decreased diffusion volume. Under bronchoscopy, the bronchial mucosa showed pigmentation, bronchial distortion or multiple stenosis, even occlusion, and bronchial mucosa edema or congestion. Echocardiography and catheterization of the right heart showed that pulmonary hypertension and diastolic cardiac dysfunction were common complications of fibrillary mediastinum. Pulmonary ventilation perfusion imaging showed impaired blood perfusion in 87.5% of patients and impaired ventilation perfusion in 37.5% of patients. The symptoms of some patients alleviated after anti-infective and symptomatic treatment, but the mediastinal fibrosis was irreversible, and the efficacy of anti-tuberculosis and glucocorticoid therapy was limited. ConclusionsFor patients with clinical consideration of fibrous mediastinum, chest enhanced CT should be performed for clear diagnosis. Relevant examinations, such as pulmonary function, endoscopic, echocardiography, should be conducted to evaluate whether the disease involves airway, pulmonary vessels, pericardium, superior vena cava and esophagus, as well as the degree of functional involvement. Attention should be paid to the evaluation of patients with pulmonary hypertension and diastolic cardiac insufficiency.
Objective To investigate the etiology, symptoms, diagnosis, surgical treatment, and outcomes of acute necrotizing mediastinitis (ANM) in order to guide future diagnosis and treatment of ANM. Methods The clinical data of patients with ANM referred to West China Hospital, Sichuan University from March 2012 to April 2021 were retrospectively analyzed. The etiology, clinical manifestations, demographic characteristics, bacterial culture results, surgical approach and prognostic factors of these patients were summarized. ResultsA total of 176 patients were enrolled in this study. The median age was 60 ( 0-84) years. There were 124 (70.5%) males and 52 (29.5%) females. The most common origin of infection was neck (n=66, 37.5%). The most common symptom was fever (n=85, 48.3%). Streptococcus constellatus represented the most common pathogens in secretion culture. Surgical treatment was administered to 119 (67.6%) patients through different approaches, including 54 (30.7%) patients of cervical approach, 9 (5.1%) patients of thoracotomy, 18 (10.2%) patients of video-assisted thoracoscopic surgery (VATS), 7 (4.0%) patients of cervical combined with thoracotomy, 30 (17.0%) patients of cervical combined with VATS, and 1 (0.6%) patient of subxiphoid approach. Among this cohort, 144 (81.8%) patients were cured, while 32 (18.1%) patients died. Age-adjusted Charlson comorbidity index (OR=2.95, P=0.022), perioperative sepsis (OR=2.84, P=0.024), and non-surgical treatment (OR=2.41, P=0.043) were identified as independent predictors of poor outcomes. Conclusion For patients with corresponding history and manifestations of ANM, it is crucial to go through imaging examination to confirm the presence of an abscess and guide the selection of surgical approach. Once the diagnosis of ANM is made, it is imperative to promptly perform surgical intervention for effective drainage. Our study highlights the significance of age-adjusted Charlson comorbidity index, perioperative sepsis and surgical treatment in predicting patients’ outcomes.